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NICE cancer referral criteria ignore GPs’ ‘sixth sense’, RCGP cancer lead warns

Exclusive: GPs are being forced to ‘manipulate' the two-week cancer pathway by inflexible NICE referral criteria that make no allowances for their ‘sixth sense', the RCGP's lead on cancer has warned.

Professor Greg Rubin, RCGP and Cancer Research UK clinical lead on cancer, claimed two-week wait GP referrals were being wrongly categorised as ‘inappropriate' by NICE guidance that focuses on ‘red flags', as just half of patients with cancer present with red-flag symptoms.

In an exclusive interview with Pulse – the second in our Big Interview series with key figures in general practice – he said it was often a GPs' intuition that dictated whether a cancer was detected early, citing a study from last year that found 7.7% of patients referred ‘inappropriately' by GPs were found to have cancer.

Professor Rubin revealed that new figures to be published next month will show just 11% of referrals under the two-week wait pathway go on to have a diagnosis confirmed. He said the data showed that NICE's referral criteria needed to be revised and that GPs required much better access to diagnostic support before making a referral.

His comments come after GPs were criticised earlier this week for a threefold variation in cancer referral rates through the two-week wait pathway.

But Professor Rubin said absolute numbers were not as important as diagnosis rates and that some practices referred fewer patients but had a higher detection rate.

He admitted UK rates of early diagnosis were ‘less good' than other comparable countries, and part of this was because current NICE guidance was a barrier to referrals.

He said: ‘[NICE guidance] probably is a bit of a barrier. GPs also have a sixth sense when something could be wrong. Sometimes they squeeze patients into the two-week wait pathway and sometimes specialists complain about that.

‘But the fact of the matter is that while 11% of all two-week wait referral patients have cancer, about 18% of those that are appropriately referred have cancer – but interestingly, 7.7% of those inappropriately referred also have cancer. So GPs sometimes have to manipulate the two-week wait system to get patients seen who they have got a pretty good idea might have cancer.

‘The guidance is okay as it stands, but it really only addresses alarm symptoms, and 50% of patients don't have alarm symptoms. Something better is needed.'

He also said that changing models of care and giving GPs access to diagnostic tests should be a priority: ‘NICE is in the process of reviewing guidance, but we also need to think about models of care and the access for GPs to diagnostic tests.'

He said future options could include diagnostic centres where patients can be tested more easily than going through a two-week wait referral pathway. He also backed the introduction of new symptom assessment tools for cancer – such as QCancer and RATS – into GP practices.

Professor Rubin said: ‘Risk assessment tools are almost certainly one of the ways forward. Which one is going to be best is currently uncertain – it is probably going to be a combination of all of them.'

Pulse revealed in April that two-thirds of PCTs have yet to provide GPs with access to the full set of cancer diagnostics identified by the Department of Health as a high priority for earlier diagnosis.

A NICE spokesperson said: 'The NICE clinical guideline which outlines the care that a patient with suspected cancer should receive is in the process of being updated to ensure recommendations remain based on the best, up-to-date evidence so patients receive a timely referral and effective care.

'The update for this guideline is not due to be published before 2014 and until then, healthcare professionals should continue to follow the recommendations set out in the current guideline.'

Click here for The Big Interview with Professor Greg Rubin


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